What Is Surgry

What Is Heart Surgery?
Heart surgery is done to correct problems with the heart. Many heart surgeries are done each year in the United States for various heart problems. Heart surgery is used for both children and adults. This article discusses heart surgery for adults. For more information about heart surgery for children, go to the Health Topics articles about congenital heart defects, holes in the heart, and tetralogy of Fallot.

Doctors also use heart surgery to:

• Repair or replace heart valves, which control blood flow through the heart
• Repair abnormal or damaged structures in the heart
• Implant medical devices that help control the heartbeat or support heart function and blood flow
• Replace a damaged heart with a healthy heart from a donor
• Traditional heart surgery, often called open-heart surgery, is done by opening the chest wall to operate on the heart. The surgeon cuts through the patient's breastbone (or just the upper part of it) to open the chest.

Once the heart is exposed, the patient is connected to a heart-lung bypass machine. The machine takes over the heart's pumping action and moves blood away from the heart. This allows the surgeon to operate on a heart that isn't beating and that doesn't have blood flowing through it.

Another type of heart surgery is called off-pump, or beating heart, surgery. It's like traditional open-heart surgery because the chest bone is opened to access the heart. However, the heart isn't stopped, and a heart-lung bypass machine isn't used. Off-pump heart surgery is limited to CABG.

Surgeons can now make small incisions (cuts) between the ribs to do some types of heart surgery. The breastbone is not opened to reach the heart. This is called minimally invasive heart surgery. This type of heart surgery may or may not use a heart-lung bypass machine.

Types of Heart Surgery
Coronary Artery Bypass Grafting
Coronary artery bypass grafting (CABG) is the most common type of heart surgery. CABG improves blood flow to the heart. Surgeons use CABG to treat people who have severe coronary heart disease (CHD).

CHD is a disease in which a waxy substance called plaque (plak) builds up inside the coronary arteries. These arteries supply oxygen-rich blood to your heart.

Over time, plaque can harden or rupture (break open). Hardened plaque narrows the coronary arteries and reduces the flow of oxygen-rich blood to the heart. This can cause chest pain or discomfort called angina (an-JI-nuh or AN-juh-nuh).

If the plaque ruptures, a blood clot can form on its surface. A large blood clot can mostly or completely block blood flow through a coronary artery. This is the most common cause of a heart attack. Over time, ruptured plaque also hardens and narrows the coronary arteries.

During CABG, a healthy artery or vein from the body is connected, or grafted, to the blocked coronary artery. The grafted artery or vein bypasses (that is, goes around) the blocked portion of the coronary artery. This creates a new path for oxygen-rich blood to flow to the heart muscle. Surgeons can bypass multiple blocked coronary arteries during one surgery.

Angioplasty (AN-jee-oh-plas-tee) is another treatment for CHD. This procedure opens narrow or blocked coronary arteries.During angioplasty, a thin, flexible tube with a balloon at its tip is threaded through a blood vessel to the narrow or blocked coronary artery. Once in place, the balloon is inflated to push the plaque against the artery wall. This restores blood flow through the artery.

During angioplasty, a stent might be placed in the coronary artery to help keep it open. A stent is a small mesh tube that supports the inner artery wall.

If both CABG and angioplasty are options, your doctor can help you decide which treatment is right for you.
Transmyocardial Laser Revascularization
Transmyocardial (tranz-mi-o-KAR-de-al) laser revascularization (re-VAS-kyu-lar-ih-ZA-shun), or TMR, is surgery used to treat angina when no other treatments work.

For example, if you've already had one CABG procedure and can't have another one, TMR might be an option. This type of heart surgery isn't common.

During TMR, a surgeon uses lasers to make small channels through the heart muscle and into the heart's lower left chamber (the left ventricle).

It isn't fully known how TMR relieves angina. The surgery may help the heart grow tiny new blood vessels. Oxygen-rich blood may flow through these vessels into the heart muscle, which could relieve angina.

Heart Valve Repair or Replacement
For the heart to work well, blood must flow in only one direction. The heart's valves make this possible. Healthy valves open and close in a precise way as the heart pumps blood.

Each valve has a set of flaps called leaflets. The leaflets open to allow blood to pass from one heart chamber into another or into the arteries. Then the leaflets close tightly to stop blood from flowing backward.

Heart surgery is used to fix leaflets that don't open as wide as they should. This can happen if they become thick or stiff or fuse together. As a result, not enough blood flows through the valve.

Heart surgery also is used to fix leaflets that don't close tightly. This problem can cause blood to leak back into the heart chambers, rather than only moving forward into the arteries as it should.

To fix these problems, surgeons either repair the valve or replace it with a man-made or biological valve. Biological valves are made from pig, cow, or human heart tissue and may have man-made parts as well.

To repair a mitral (MI-trul) or pulmonary (PULL-mun-ary) valve that's too narrow, a cardiologist (heart specialist) will insert a catheter (a thin, flexible tube) through a large blood vessel and guide it to the heart.

The cardiologist will place the end of the catheter inside the narrow valve. He or she will inflate and deflate a small balloon at the tip of the catheter. This widens the valve, allowing more blood to flow through it. This approach is less invasive than open-heart surgery.

Researchers also are testing new ways to use catheters in other types of valve surgeries. For example, catheters might be used to place clips on the mitral valve leaflets to hold them in place.

Catheters also might be used to replace faulty aortic valves. For this procedure, the catheter usually is inserted into an artery in the groin (upper thigh) and threaded to the heart.

In some cases, surgeons might make a small cut in the chest and left ventricle (the lower left heart chamber). They will thread the catheter into the heart through the small opening.

The catheter has a deflated balloon at its tip with a folded replacement valve around it. The balloon is used to expand the new valve so it fits securely within the old valve.

Catheter procedures might be a safer option for patients who have conditions that make open-heart surgery very risky. Only a few medical centers are doing these experimental procedures. However, the results may lead to improved heart surgery approaches.

Arrhythmia Treatment
An arrhythmia (ah-RITH-me-ah) is a problem with the rate or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too slow, or with an irregular rhythm.

Many arrhythmias are harmless, but some can be serious or even life threatening. If the heart rate is abnormal, the heart may not be able to pump enough blood to the body. Lack of blood flow can damage the brain, heart, and other organs.

Medicine usually is the first line of treatment for arrhythmias. If medicine doesn't work well, your doctor may recommend surgery. For example, surgery may be used to implant a pacemaker or an implantable cardioverter defibrillator (ICD).

A pacemaker is a small device that's placed under the skin of your chest or abdomen. Wires connect the pacemaker to your heart chambers. The device uses low-energy electrical pulses to control your heart rhythm. Most pacemakers have a sensor that starts the device only if your heart rhythm is abnormal.

An ICD is another small device that's placed under the skin of your chest or abdomen. This device also is connected to your heart with wires. An ICD checks your heartbeat for dangerous arrhythmias. If the device senses one, it sends an electric shock to your heart to restore a normal heart rhythm.

Another arrhythmia treatment is called maze surgery. For this surgery, the surgeon makes new paths for the heart's electrical signals to travel through. This type of surgery is used to treat atrial fibrillation, the most common type of serious arrhythmia.

Simpler, less invasive procedures also are used to treat atrial fibrillation. These procedures use high heat or intense cold to prevent abnormal electrical signals from moving through the heart.

Aneurysm Repair
An aneurysm (AN-u-rism) is a balloon-like bulge in the wall of an artery or the heart muscle. This bulge can occur if the artery wall weakens. Pressure from blood moving through the artery or heart causes the weak area to bulge.

Over time, an aneurysm can grow and burst, causing dangerous, often fatal bleeding inside the body. Aneurysms also can develop a split in one or more layers of the artery wall. The split causes bleeding into and along the layers of the artery wall.

Aneurysms in the heart most often occur in the heart's lower left chamber (the left ventricle). Repairing an aneurysm involves surgery to replace the weak section of the artery or heart wall with a patch or graft.

Heart Transplant
A heart transplant is surgery to remove a person's diseased heart and replace it with a healthy heart from a deceased donor. Most heart transplants are done on patients who have end-stage heart failure.

Heart failure is a condition in which the heart is damaged or weak. As a result, it can't pump enough blood to meet the body's needs. "End-stage" means the condition is so severe that all treatments, other than heart transplant, have failed.

Patients on the waiting list for a donor heart receive ongoing treatment for heart failure and other medical conditions. Ventricular assist devices (VADs) or total artificial hearts (TAHs) might be used to treat these patients.

Open-Heart Surgery
Open-heart surgery is any kind of surgery in which a surgeon makes a large incision (cut) in the chest to open the rib cage and operate on the heart. "Open" refers to the chest, not the heart. Depending on the type of surgery, the surgeon also may open the heart.

Open-heart surgery is used to do CABG, repair or replace heart valves, treat atrial fibrillation, do heart transplants, and place VADs and TAHs.

Off-Pump Heart Surgery
Surgeons also use off-pump, or beating heart, surgery to do CABG. This approach is like traditional open-heart surgery because the chest bone is opened to access the heart. However, the heart isn't stopped, and a heart-lung bypass machine isn't used.

Off-pump heart surgery isn't right for all patients. Work with your doctor to decide whether this type of surgery is an option for you. Your doctor will carefully consider your heart problem, age, overall health, and other factors that may affect the surgery.

Minimally Invasive Heart Surgery
For minimally invasive heart surgery, a surgeon makes small incisions (cuts) in the side of the chest between the ribs. This type of surgery may or may not use a heart-lung bypass machine.

Minimally invasive heart surgery is used to do some bypass and maze surgeries. It's also used to repair or replace heart valves, insert pacemakers or ICDs, or take a vein or artery from the body to use as a bypass graft for CABG.

One type of minimally invasive heart surgery that's still being developed is robotic-assisted surgery. For this surgery, a surgeon uses a computer to control surgical tools on thin robotic arms.

The tools are inserted through small incisions in the chest. This allows the surgeon to do complex and highly precise surgery. The surgeon always is in total control of the robotic arms; they don't move on their own.

Who Needs Heart Surgery?

Heart surgery is used to treat many heart problems. For example, it's used to:

• Treat heart failure and coronary heart disease (CHD)
• Fix heart valves that don't work well
• Control abnormal heart rhythms
• Place medical devices
• Replace a damaged heart with a healthy one
• If other treatments—such as lifestyle changes, medicines, and medical procedures—haven't worked or can't be used, heart surgery might be an option.

Specialists Involved
Your primary care doctor, a cardiologist, and a cardiothoracic (KAR-de-o-tho-RAS-ik) surgeon will work with you to decide whether you need heart surgery.

A cardiologist specializes in diagnosing and treating heart problems. A cardiothoracic surgeon specializes in surgery on the heart and lungs.

These doctors will talk with you and do tests to learn about your general health and your heart problem. They'll discuss the test results with you and help you make decisions about the surgery.

Medical Evaluation
Your doctors will talk with you about:

• The kind of heart problem you have and the symptoms it's causing. Your doctor may ask you how long you've had symptoms.
• Your past treatment of heart problems, including surgeries, procedures, and medicines.
• Your family's history of heart problems.
• Your history of other health problems, such as diabetes or high blood pressure.
• Your age and general health.
• You also may have blood tests, such as a complete blood count, a lipoprotein panel (cholesterol test), and other tests as needed.

Diagnostic Tests
Tests are done to find out more about your heart problem and your general health. This helps your doctors decide whether you need heart surgery, what type of surgery you need, and when to do it.

EKG (Electrocardiogram)
An EKG is a painless, noninvasive test that records the heart's electrical activity. "Noninvasive" means that no surgery is done and no instruments are inserted into your body.

The test shows how fast the heart is beating and its rhythm (steady or irregular). An EKG also records the strength and timing of electrical signals as they pass through the heart.An EKG can show signs of heart damage due to CHD and signs of a previous or current heart attack.

Stress Test
Some heart problems are easier to diagnose when your heart is working hard and beating fast. During stress testing, you exercise to make your heart work hard and beat fast. If you can't exercise, you may be given medicine to raise your heart rate.

As part of the test, your blood pressure is checked and an EKG is done. Other heart tests also might be done.

Echocardiography
Echocardiography (echo) is a painless, noninvasive test. This test uses sound waves to create a moving picture of your heart. Echocardiography shows the size and shape of your heart and how well your heart chambers and valves are working.

The test also can show areas of poor blood flow to your heart, areas of heart muscle that aren't working well, and previous injury to your heart muscle caused by poor blood flow.

Coronary Angiography
Coronary angiography (an-jee-OG-rah-fee) is a test that uses dye and special x rays to show the insides of your coronary arteries.

To get the dye into your coronary arteries, your doctor will use a procedure called cardiac catheterization (KATH-eh-ter-ih-ZA-shun).

A thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck. The tube is threaded into your coronary arteries, and the dye is released into your bloodstream.

Special x rays are taken while the dye is flowing through the coronary arteries. These x rays are called angiograms.

The dye lets your doctor study blood flow through the heart and blood vessels. This helps your doctor find blockages that can cause a heart attack.

Chest X Ray
A chest x ray creates pictures of the structures inside your chest, such as your heart, lungs, and blood vessels.

This test gives your doctor information about the size and shape of your heart. A chest x ray also shows the position and shape of the large arteries around your heart.

Cardiac Computed Tomography Scan
A cardiac computed tomography (to-MOG-rah-fee) scan, or cardiac CT scan, is a painless test that uses an x-ray machine to take clear, detailed pictures of the heart.

Sometimes an iodine-based dye (contrast dye) is injected into one of your veins during the scan. The contrast dye highlights your coronary (heart) arteries on the x-ray pictures. This type of CT scan is called a coronary CT angiography, or CTA.

A cardiac CT scan can show whether plaque is narrowing your coronary arteries or whether you have an aneurysm. A CT scan also can find problems with the heart's function and valves.
Cardiac Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) is a safe, non invasive test that uses magnets, radio waves, and a computer to create pictures of your organs and tissues.

Cardiac MRI creates images of your heart as it is beating. The computer makes both still and moving pictures of your heart and major blood vessels.

Cardiac MRI shows the structure and function of your heart. This test can show the size and location of an aneurysm.

PHYSIOTHERAPY MANAGEMENT

Cardiorespiratory Physical Therapy
Patients were seen preoperatively at 7 of the 18 sites. Patients were seen for assessment and treatment on the first postoperative day (POD-1) at 16 sites. Most sites (12/18) saw patients on one occasion on POD-1. The most common treatment (16/18 sites) was DB&C. Eight sites reported the use of incentive spirometers on POD-1, and 12 sites provided education around self-treatments (DB&C, bed exercises) and treatment progression. Nine sites continued to provide cardiorespiratory treatment on POD-3. Further information on cardiorespiratory assessment and treatment patterns over the first 3 postoperative days is provided in Table Table22

Mobility
There was wide variation in mobility treatment as a result of staffing constraints, surgeons' preferences (e.g., gait aids), usual care, and nursing practice. Table Table33 provides information on mobilization programs on POD-1 through POD-3. Patients were seated on the edge of the bed (“dangled”) at 17 sites and mobilized out of bed at 13 sites. Patients were ambulated in the hall in only a single hospital on POD-1 but in 15 on POD-2 and in 18 by POD-3. All sites reported that patients were ambulated 50–120 m per session, three to five times per day. Responsibility for mobilization was generally shared between physical therapists and nurses; at five sites, nurses took on the primary role if there were no mobility issues. Physical therapists reported being more involved with complex patients.

Mobilization on Postoperative Days 1–3
Stair assessments were inconsistent. Four sites reported assessing all patients on stairs before discharge; six sites assessed patients only if stairs were present in the patient's home, while seven sites assessed patients if there were mobility concerns (new or previous gait aid, balance deficit,